Thursday, August 29, 2013

C-Reactive Protein: A Measure Of Oxidative Stress

Your body constantly reacts with oxygen as you breathe and your cells produce energy. As a consequence of this activity, highly reactive molecules are produced within our cells known as free radicals. If your body is unable to stop the spiraling free radical chain reaction (a molecule stealing an electron from another molecule, causing that molecule to steal an electron from another molecule, causing that molecule to steal an electron, etc...) this can cause oxidative damage to proteins, membranes and genes.

Bombardment of cells by free radicals.
When oxidation is excessive and the body is unable to neutralize high levels of free radicals with enough antioxidants, we refer to this as oxidative stress. The deeper the body goes into oxidative stress the more extensive will be the cellular damage that will then trigger an inflammatory response. Free radical damage, oxidative stress and systemic inflammation are all implicated in a number of chronic degenerative disease states and premature aging.

If oxidative stress continues for days, weeks or months, the body can go into a condition called chronic systemic low-grade inflammation. This type of inflammation can stimulate aggressive osteoclastic bone resorption and lead to osteoporosis.

Unfortunately, there is no one test that will tell us if a person has this type of inflammation. But there are tests for general inflammation and others for oxidative stress which, when reviewed in conjunction with the person's signs and symptoms, can give us a good indication of whether that individual has chronic systemic inflammation.

A recent paper by Park et al. in Clinical Endocrinolgy shows that C-reactive protein (CRP), a protein in the blood that rises in response to inflammation, is also a measurement of oxidative stress. The study involved 1821 nondiabetic postmenopausal women with elevated CRP (≤ 10 mg/l) levels. The researchers used an oxidized low-density lipoprotein, a known marker of oxidative stress, to compare with CRP. The authors concluded that CRP is strongly associated with oxidative stress.

Oxidative stress and its impacts can be alleviated with early detection. Having lab markers such as C-reactive protein to provide important clues to the causes of bone loss is of great benefit to a clinician designing a diet/nutrition therapeutic protocol for chronic disease conditions such as osteoporosis. 

Park, S. et al. 2013. Oxidative stress is associated with C-reactive protein in nondiabetic postmenopausal women, independent of obesity and insulin resistance. Clinical Endocrinology 79, 65-70.

Wednesday, August 28, 2013

Mass Appeal Segment on Osteoporosis With Ashley Kohl

I had a great time today as a guest on Channel 22's (WWLP) Mass Appeal TV show in Springfield, MA. Ashley Kohl was the host and we talked about the importance of recognizing patient biochemical individuality when assessing the causes of osteoporosis and determining treatment protocol. Ashley was a phenomenal host...so kind and gracious and professional. Actually, the whole staff at Mass Appeal was great. I was a bit nervous but everyone was so supportive that it made it a lot easier being in front of the cameras. Here's the link if you want to watch.  

Friday, August 23, 2013

Strontium: Does It Actually Build Bone Mass Or Just Look Like It?

There has been considerable debate over the benefits of strontium for treating osteoporosis. Prior research indicates strontium ranelate both increases bone mineral density and reduces fractures of the spine (but not the hip) by up to 40%. Although the benefits of strontium look promising, it has been difficult to determine how much of strontium's effect on bone density is from a real increase in bone mass and how much of it is simply artifact. The strontium atom is almost twice as heavy as calcium (38 vs 20 on the atomic chart) and when strontium enters bone tissue it creates more impedance to x-rays. On subsequent bone density (DXA) examinations, this creates the illusion of a higher than actual improvement in bone density.

In a recently accepted article for publication in the Journal of Bone and Mineral Research,
Chavassieux et al. compared the effects of strontium ranelate and alendronate (a bisphosphonate) on bone. Strontium is often considered to have both an antiresorptive effect by reducing osteoclast cell activity plus an anabolic effect by stimulating osteoblasts to form bone. Alendronate, on the other hand, is only antiresorptive in its therapeutic effect.

The study included 387 postmenopausal women with osteoporosis. Bone biopsies (transiliac) were performed at baseline and then again after 6 or 12 months to determine the effects of these two medications. The results indicated that although bone formation remained higher and there was overall less of a decrease in bone remodeling with strontium compared with alendronate, the strontium did not show significant anabolic (bone building) action.

Chavassieux, P., et al. 2013. Bone histomorphometry of transiliac paired bone biopsies after 6 or 12 months of treatment with oral strontium ranelate in 387 osteoporotic women. Randomized comparison to alendronate. Journal of Bone and Mineral Research doi: 10.1002/jbmr.2074.

Thursday, August 22, 2013

Jumping Power: A Better Test For Sarcopenia Than Muscle Strength

In a study from the Department of Health and Exercise Science at the University of Oklahoma, Singh et al. examined the relationship between jumping power, muscle strength and sarcopenia (the loss of muscle mass seen with aging and illness). Sarcopenia is often seen with osteoporosis and leads to weakness with an increased risk for falls and fractures.

This study is fascinating because it showed that individuals with
sarcopenia had significantly lower jumping power but not necessarily lower muscle strength when compared to individuals without sarcopenia. "Based on our findings, JPow [jumping power] may be useful for sarcopenia screening in the middle-aged and older adults; however, more research is needed to determine the utility of this method in clinical populations." [No...their method did not include having men and women 55 to 75 years of age jump over cows.]

Singh, H, et al. 2013. Jump test performance and sarcopenia status in men and women, 55 to 75 years of age. J Geriatr Phys Ther August 16. [Epub ahead of print]

Sunday, August 18, 2013

Alpha-Lipoic Acid Increases Bone Mineral Density--Protects Against Bone Loss

Alpha-lipoic acid (thioctic acid) is a powerful antioxidant and free-radical scavenger. It is also an essential cofactor for mitochondrial enzymes that stimulate energy production. Unlike other antioxidants that act only in water (such as vitamin C) or fat (vitamin E), alpha-lipoic acid can access all areas of the body...even the fatty contents of your bone marrow. This is important because it is within your marrow that cellular "coupled" activity determines the health and density of your bones. Alpha-lipoic acid can help maintain balance between the osteoclasts that tear down bone and the osteoblasts that form bone.

The following are some of the powerful benefits related to bone health that we have seen with alpha-lipoic acid:     

-  Protects against oxidative stress which is part of the inflammatory process that
    drives bone loss.
-  Reduces the proinflammatory cytokines (Il-1, Il-6, TNF-alpha) that stimulate
    osteoclast activity.
-  Lowers NF-kB, the protein that commands a cell's nucleus to turn on
    inflammatory-inducing genes.
-  Reduces RANKL, the signaling molecule that activates osteoclasts.
-  Activates the enzyme AMPK (a negative regulator of RANKL) in osteoclasts.
-  Inhibits the production of advanced glycation end-products (AGEs) seen with
    elevated glucose levels. AGEs make bone stiff and vulnerable to breaking.
-  Chelator of heavy metals that can cause bone loss.
-  Suppresses osteoclast formation.
-  Inhibits excess bone resorption.


recent study conducted by Beyzagul, et al. out of Turkey used rats to assess the effect of alpha-
lipoic acid on bone metabolism. The researchers concluded that alpha-lipoic acid "had a protective effect on both senile [inflammation induced] and postmenopausal osteoporosis" and that it "may be a candidate for radical osteoporosis treatment." This is one more study that we can add to the volumes of research before it showing the benefits of alpha-lipoic acid for bone health.

Dietary sources of alpha-lipoic acid are minimal and endogenous (within the body) production, especially during times of stress or disease, is insufficient for controlling oxidative stress and promoting optimal energy production. This is why supplemental alpha-lipoic acid can be so beneficial and it is why we at OsteoNaturals include alpha-lipoic acid as a primary ingredient (300 mg) in our OsteoStim. Yes, as the authors of this study write, alpha-lipoic acid can be a "radical osteoporosis treatment"...but then, we've always known that OsteoNaturals formulas are way ahead of the curve.

Beyzagul P. et al. 2013. The effect of alpha-lipoc acid in ovariectomy and inflammation-mediated osteoporosis on the skeletal status of rat bone. Eur J Pharmacol doi: 10.1016/j.ejphar.2013.07.033. [Epub ahead of print]

Wednesday, August 14, 2013

Wakefield Marathon

As many of you may know by now, my race to qualify for the Boston Marathon went fairly well...considering I wasn't in the best of shape. The marathon was in Wakefield, MA--the Around the Lake Marathon. I finished in 3:37, just under the 3:40 Boston qualifying time for my age (59). It was a fun race...(if you consider running 26.2 miles fun)...but I sure was stiff and sore for a few days afterwards.

I just thought I would show everyone the absolutely GORGEOUS rainbow that came out to add brilliance to the course. This may be the brightest rainbow I've ever seen...and a double one at that!

Sunday, August 11, 2013

Magnesium--A Key Mineral in Human Metabolism

Magnesium (Mg) is one of the most important nutrients in your body. It is involved in cell energy
Magnesium's central position in the chlorophyll molecule
metabolism, muscle tone (including heart contractions), nerve conduction, cell membrane formation and maintenance, electrolyte balance, enzyme function, and in biological mechanisms that protect you from the damaging effects of inflammation and free-radicals. Magnesium is also absolutely vital for good bone health. It is used by osteoblasts to build new bone and it is necessary for the production of bone-regulating calcitonin and parathyroid hormones. Magnesium is also important for preventing calcium from depositing into soft tissues.

Unfortunately, magnesium deficiency is common, and more so in older adults. In fact, it has been estimated that up to 80 percent of elderly individuals are deficient in magnesium. Magnesium can be difficult to absorb and as we age reduced digestive capacity lowers absorption further. Stress and disease also contribute to increased magnesium demands.

Signs of magnesium deficiency can include muscle spasms, skin twitching below the eye, constipation, hypertension, rapid heart rate, arrhythmias, depression, fatigue, asthma, muscle weakness, irritability, and hypersensitive skin.

How can you know for sure if you have magnesium deficiency? The gold standard lab test for determining magnesium levels is to evaluate the levels in red blood cells. (Blood serum testing is not a good indicator for magnesium because most (99%) of this mineral is stored within cells and not in the extracellular fluids.) In addition, because deficient magnesium can affect many systems throughout the body, other lab results may alert the physician (or you) that a red blood cell analysis of magnesium is indicated. The following labs are the most helpful:

-  Low serum calcium.
-  Low serum potassium
-  Low active vitamin D or calcitriol [1,25(OH)2D]
-  Elevated parathyroid hormone (PTH)
-  Low osteocalcin
-  Elevated C-reactive protein (hs-CRP)

It pays to ensure that you get adequate magnesium before signs of deficiency occur. Your best sources of dietary magnesium are found in whole grains, seeds, nuts, and especially in green vegetables (Notice the central position of the magnesium ion in the chlorophyll molecule in the picture...chlorophyll is what gives plants their green color and the ability to absorb energy from light.) But magnesium supplementation (300 to 600 mg/day), especially if you have bone loss, is usually a good idea. I've always touted the virtues of high-end magnesium sources such as what I use in our OsteoNaturals products. OsteoSustain is formulated with Albion's TRAACS magnesium glycinate chelate and our OsteoMineralBoost has dimagnesium malate. Both of these forms of magnesium are known for their superior absorbability and effectiveness.

I have always complained about vitamin-mineral products that used magnesium oxide and felt that they were inferior. Well...not so fast...I may have to eat my words. Research by Shechter et al. recently demonstrated that supplemental magnesium oxide was actually superior to magnesium citrate for increasing intracellular magnesium levels. Magnesium oxide also appeared to be more effective in reducing hs-CRP. This is pretty impressive so, even though there are some limitations* to this study, I will go a bit easier on magnesium oxide from now on. I'm not thoroughly convinced, but at least I will not object so vehemently.

     * My concerns about this study:  The author's choice to use x-ray dispersion analysis
      for measuring intracellular magnesium is not your standard testing method. In my
      opinion, it would have been better to have included the tried-and-true red blood cel
      l analysis in the study for comparison. Secondly, one of the authors of the study is
      the Research Director and President of IntraCellular Diagnostics, Inc., the company
      that uses this form of magnesium testing commercially. And finally, the researchers
      used two different dosages of magnesium products for their comparison: Diasporal
      (magnesium citrate) has 295.8 mg of elemental magnesium while Magnox
      (magnesium oxide) has 520 mg of elemental magnesium. This is a huge discrepancy
      and one that may indeed invalidate the study.

Shechter M. et al. 2012. Comparison of magnesium status using X-ray dispersion analysis following magnesium oxide and magnesium citrate treatment of healthy subjects. Magnesium Research 25(1):28-39.   


Saturday, August 3, 2013

FDA Defines "Gluten Free"

The Food and Drug Administration has finally issued gluten-free labeling regulations. Their ruling this week provides a uniform
standard definition that requires food labeled as gluten-free to contain less than 20 parts per million of gluten.

Thursday, August 1, 2013

Spinal Compression Fractures

Almost a million osteoporosis-related spinal compression fractures occur each year in the United
States. To put that number into perspective, that's approximately one out of every 80 people over the age of 55... EACH year. This is not just a fracture in their lifetime, but THIS year. And, once a person has sustained one compression fracture, the chances of them sustaining another within a year increases 4- to 6-fold! This phenomena is referred to as "vertebral fracture cascade." With so many fractures, it is easy to understand why osteoporosis has become the most common metabolic bone disorder in America. The loss of mineral density (bone thinning) and microarchitectural quality from bone is what makes them susceptible to breaking. Although the hips, ribs and spine are the most commonly fractured bones due to osteoporosis, every bone is at increased risk for fracture.

Compression fractures of the spine can result from major trauma such as falling backwards onto the buttocks, or from minor traumas such as bending, lifting, coughing, or twisting. When bone is EXTREMELY fragile, fractures can result from simply walking around or changing positions such as bending forward to sit down. When the spine structure is severely weakened, it doesn't take much strain at all for the vertebrae to simply collapse.

When I fractured one of my thoracic vertebra while running many years ago, the pain lasted for about a year. While this is not unusual, nearly 50% of vertebral compression fractures cause minimal or no pain and may go undetected. In fact, many of these fractures are discovered as secondary findings when radiological procedures are being performed for other medical reasons. (Tip: if you have had radiographs taken and read at a medical facility, it is a VERY good idea to have your chiropractor double check them.)

So how do you know if you have sustained a vertebral compression fracture? Typically your chiropractor or medical physician will be able to find a localized area of tenderness when they are examining your spine. He or she may also notice an increased kyphotic or forward angulation in your spine if there is a fracture in the thoracic area. Thoracic and lumbar spine fractures are the most common areas to sustain compression fractures although they can occur in the cervical spine also. If your doctor suspects a fracture, x-rays will be ordered. A bone scan, CT (computed tomography), and/or MRI (magnetic resonance imaging) may also be indicated to determine if the fracture has occurred recently or if it is old. These tests can also help your doctor evaluate any neurological involvement and also to rule out any suspicion of cancer.

Treatment options? In 2010, the American Academy of Orthopaedic Surgeons approved new clinical guidelines for the treatment of osteoporotic spine compression fractures. According to Dr. Robert A McGuire, vice-chair of the work group:
 
"Treatment of these fractures has focused on relieving pain and restoring mobility and function. Although most fractures heal within a few months, some people have continuing pain and disability.

Both surgical and nonsurgical treatments are available. Surgical treatments may include minimally invasive procedures such as vertebroplasty (an injection of cement directly into the vertebral body and kyphoplasty (use of ballon to expand the compressed space prior to the injection of bone filer.) Nonsurgical treatments include the use of pain relievers, braces, electrical stimulation, and exercise. Additionally, complementary or alternative medical treatments such as acupuncture, massage, or the use of dietary supplements have been applied."

Most vertebral compression fractures are treated through conservative, nonsurgical care. They typically heal on their own within eight to ten weeks but I am often asked about vertebroplasty and kyphoplasty. Both of these procedures have come under considerable scrutiny, not only due to the significant risk of adverse effects such as bleeding, infection allergic reactions, and leakage of bone cement into the surrounding tissues, but also regarding questions concerning their long-term benefit. In fact, many believe that these procedures may increase the risk of the fracture cascade by placing undue mechanical stress on adjacent vertebrae. The 2010 guidelines address these concerns. Dr. McGuire continues:

"The recommendations also consider two surgical procedures often used to treat vertebral compression fractures: vertebroplasty and kyphoplasty. The single strong recommendation in the guidelines is based on two Level I studies comparing vertebroplasty to a sham procedure, and three Level II studies comparing vertebroplasty to conservative treatment:

We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact. By making a strong recommendation against the use of vertebroplasty, the group is expressing its confidence that future evidence is unlikely to overturn the results of these trials.

The guidelines consider kyphoplasty to be an option (weak recommendation). Although the two Level II studies that compared kyphoplasty to conservative treatment did find clinically important pain relief at various points, both were flawed. The three studies comparing kyphoplasty to vertebroplasty had inconsistent results. 

Although kyphoplasty and vertebroplasty are similar procedures, the evidence supports treating them differently within the recommendations. In a comparison of kyphoplasty to conservative treatment, for example, possibly clinically important differences for critical outcomes were seen for up to 12 months; comparing vertebroplasty to conservative treatment showed possibly clinically important differences for these outcomes only on the first day after surgery. Additionally, a direct comparison between the two procedures showed a possibly clinically important advantage in critical outcomes for kyphoplasty at up to 2 years. The fact that these results were not consistent among all studies, however, lowered the confidence level that future research will confirm the results of current evidence and resulted in the "weak" recommendation."

More recently, the risk of developing compression fractures in vertebra located adjacent to the cemented vertebroplasty-repaired vertebra was analyzed by Martinez-Ferrer et al. from Spain and published in the August 2013 edition of the Journal of Bone and Mineral Research. These researchers found "nearly 30% of patients with osteoporotic VF [vertebral fracture] treated with VP [vertebroplasty] presented a new VF after the procedure." They found that leakage of cement into the disk beneath the vertebra being repaired contributed up to a six-fold increased risk for developing a new vertebral fracture. When hard cement leaks into the disk this places increased mechanical pressure on the vertebra below. The authors state that other comparative studies indicate a similar problem with kyphoplasty. In addition to cement leakage, which occurs in 15% of vertebroplasty procedures, vitamin D deficiency was also associated with an increased risk of vertebral fracture after vertebroplasty. "Patients with levels lower than 20 ng/ml showed a greater than 15-fold increased risk for a new VF, a finding that was not observed after conservative treatment."

My recommendations:
As a chiropractor, I find that patients with spinal fractures gain considerable relief from pain and spasms through gentle massage and, when appropriate, gentle mobilization procedures. When healing of the fracture allows, stabilization of the trunk through core and balance exercises is also extremely important. As noted earlier, sustaining a vertebral compression fracture places you at a much greater risk for a second vertebral fracture or "fracture cascade." There are several key steps you can take to help avoid this structural decline of the spine.

1) Medication.  Most likely you will be placed on an osteoporosis medication, if you are not already on one.

2) Diet and Supplements.  A diet and nutrition evaluation is vital. Not only is it important that you eat a bone-healthy, anti-inflammatory diet but also adding specific supplements to your daily regimen can be crucial. The nutrients you take in not only make your bones healthier but they also help your muscles stay strong so you can avoid falls.

3) Exercise.  One of the most important things you can do to prevent fractures of the spine is to engage in specific exercises that will help improve your core, upper back and leg strength, as well as balance. Ideally, it would be best for a person to begin strengthening and stabilizing exercises as soon as they find out they have osteoporosis. This may help prevent compression fractures from ever occurring.

Once a fracture has occurred, gentle exercises can typically begin begin four to six weeks after sustaining the fracture. This is a multi-step process. Your chiropractor can help to ensure good nerve flow from your spine to your muscles. He or she may begin doing this within a week or so of the fracture depending upon the circumstances and your level of pain. I treat many patients who have sustained spinal compression fractures and their response to chiropractic care is excellent. Chiropractors are expert at evaluating the spine and ensuring that spinal alignment is optimal for nerve energy to flow to the muscles. Without good flow of nerve energy, exercises will not be as effective. Chiropractic care using gentle techniques can help reduce the pain from surrounding muscle spasms.

Specific exercises are important for improving overall strength, especially that of the trunk, upper back and leg muscles. Core strength will help stabilize your spine and prevent abnormal mechanical strains from poor spinal motion. Upper back exercises will help maintain your erect upright posture reducing any excessive kyphotic strain in your thoracic spine that could increase your risk for further fractures. Strong leg muscles are important for balance and preventing falls.

Many chiropractors and physical therapists will be able to give you safe and effective exercises for improving posture and the strength of your muscles. Consulting a Certified Exercise Specialists using the Meek's Method can be especially helpful for a comprehensive approach that includes exercises, as well as breathing and relaxation techniques. Balance exercises are also important to incorporate into your exercise regime. Most fractures occur due to falls; balance and coordination exercises will help you avoid falls.

4) Bracing.  With acute, painful, vertebral compression fractures a Jewitt-style back brace may be helpful for stabilizing the fracture and reducing pain. After a period of healing, less restrictive braces such as the Spinomed orthosis are preferable for helping to promote safe body mechanics while doing specific back strengthening exercises. Check out my previous blog Exercises and Bracing for Fracture Prevention and Pain Relief for more info on this type of bracing.

The statistics are daunting. Almost one million fractures annually. People who have sustained one osteoporotic vertebral compression fracture are at five times the risk of sustaining a second. Frequently a spinal fracture can be present with either minor symptoms or no symptoms, but the risk still exists for additional fractures to occur. There is good news, however; no matter what your age, there are many things you can do to improve your bone health and reduce fracture risk.

The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures ̴ Guideline and Evidence Report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, September 24, 2010. http://www.aaos.org/research/guideline.pdf and http://www.aaos.org/news/aaosnow/oct10/cover1.asp

Martinez-Ferrer, A. et al. 2013. Risk factors for the development of vertebral fractures after percutaneous vertebroplasty. Journal of Bone and Mineral Research 28(8):1821-1829.
    
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